Popliteal-Tibial Endarterectomy and Retrograde Femoro-Popliteal Stenting when Autologous Bypass is not an Option
Cheryl Richie, MD, David Minion, MD.
University of Kentucky, Lexington, KY, USA.
DEMOGRAPHICS: A 79 year old male presents with gangrenous ulceration of right transmetatarsal amputation site and 2 weeks of rest pain.
HISTORY: Patient is s/p transmetatarsal amputation and femoro-popliteal stenting 5 months prior for acute ischemia and a 1.5 cm thrombosed popliteal aneurysm. Operative notes revealed that overlapping 5 mm and 6 mm self-expanding covered stents were used in conjunction with angioplasty of the tibial peroneal trunk. Current CTA demonstrates occlusion of prior stents and severe atherosclerosis of the trifurcation. Vein mapping showed marginal saphenous vein.
PLAN: Operative exploration confirmed only 5 cm of usable saphenous vein. The distal superficial femoral artery and trifurcation were exposed for possible prosthetic bypass. A longitudinal arteriotomy in the tibial-peroneal trunk revealed severe focal plaque and endarterectomy was performed. The end of the most distal stent was visualized and freely mobile after endarterectomy. The stents were therefore extracted. Thrombectomy of the native artery was performed. A new 8 mm self-expanding covered stent was deployed in retrograde fashion via the tibial arteriotomy and seated with a 7 mm balloon. The arteriotomy was closed with saphenous vein patch angioplasty. At 3 months follow-up, the patient had healed wounds and normal flow on surveillance studies.
DISCUSSION: The case illustrates a novel hybrid approach for limb salvage; namely, popliteal-tibial endarterectomy with retrograde femoro-popliteal stenting. We chose this option in this patient because he had significant trifurcation disease with otherwise adequate run-off and no usable vein for tibial bypass. The endarterectomy and vein patch angioplasty created a patulous distal landing zone for the femoropopliteal stent that was not present during his initial standard endovascular procedure (Figure). Although this was performed for failed prior stenting, it would likely have utility as a primary procedure and deserves consideration as an alternative to prosthetic tibial bypass in patients without autologous options. 
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